GW1--04546_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD -- --___.
(his form can he used for single or multi)>le wclj%�'�""-� For Intamgl the ONLY:
r
I.Well Contractor Information: _
Mitchell Dean Cook 14.WA'CER%ONES\ '- — ...
_FROM_ TO--- OES(.RIPTTnN"-' '_.�._.�'_'-
Well Contractor Name f6^a//' ft. ----- -'--"-•"'
2043 A s - -
rt. r,,
NC Well Cootractot Certification Number —
6 ------�/�''
15.OUTER CASINO/for multi,cased•wells 61;LINE-if air„,__-----...---,.
FROM TO DIAMETER THICKNESS_ TERIAL.
Dennis Holland Well Drilling, Inc, -
_e ft. ft. 6 in. Q
Company Name -- O/e-o/ i I (/G
•'IC INNER CASINGOR.:TUl3MG•faeOthermat.elosed-too
FROM TO DIAMF.TF:R 'PHICKNE.SS MATERIAL
2.Well Construction Permit k: t C9.57 0,,p2 24-
f.isi all applicable well permits(i.e.County..State. Variance,Inrlon.tc..)�•-.-.___...---. ft. -- ft. -. in.
ft. ft. _io. -
3.Well Use(check well use): _ _ �- __ _
_ 17.SCREEN' - .-_.--.- ;._ _......_.....�.._.__.
Water Supply Well: '•' ,FROM TO -DIAMETER SLOT SIZE THICKNESS MATERIAL -
°Agricultural 17MtuticipaVPublic rt. rt. in.
_
I.IG 7 s
eotherinal(Heating/Cooling Supply) idential Water Supply(single) ft. ft - in. - -'
❑Industrial/Commercial L)Residential Water Supply(shared) 1g.CR9-0:- - """'�
Cllni:etion mad.__..fin._ MATERIAL 7- EMPLACEMENT METHOD&AMOUNT,
Non-Water Supply Well: --•-------• a i ft' i'r'
°htonitrning IJRecovery . •h^ fr.
Injection well: ------- - _� __ _ I
()Aquifer Recharge CJGroundwater Rentediation 19.SAND/GRAVEL PACK if a licabble —..
l3Aquifer Storage and Recovery I:JSalinity Barrier a FROM TO 'HATER IAII. EMPLACEMENT METHOD ,
ft. ft.
°Aquifer'Pest C]Stormwater Drainage ---
l7Experimental'fechnolo tt• ft.
(3Y I:JSubsidcncc Control
-20,DRILLING LOGIattrch additional sheets if necest t •UGeothermal(Closed Loop) °Tracer I ROM •O DESCRIPTION rotor,hardy is,sell/rock t _
lJGeothertnal(Heating/Cooling Rchun) DOther(explain under H21 Remakes) It ft.
4. Date Well(s)Completed: r'r'7-/Well IDk /11 4, • ---- —.._.__ _-._.
ft. -ft.
Sa.Well[.ocarina: - - • ',r-•1 y._�j
rt. ft. `.,,r_ 1
Lai Adck,'G '
Facility/Owner Name Facility 1DN(if applicable) -.._.-._.__............_. __ __._._....... _._ 1l__-.. 1_ zaz__.._...._......._
ft. ft JJ .___
Physical Address,City,and Zip 21,REMARK) ____ ^ �Na`' :j}s�•:rd'c4111 . '^.--
County Parcel Identification No.(PIN) --- --- - -- -- — -�_____..
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: -- -
(if well field,one lat/long
its sufficient)
Signature of Certified Well Contractor . Date
6. Is(are)the well(s): ) anent or f_"ITemporary
fly signing this firm.1 hereby certify that the well(s)war(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Ic tliis a repair to an existing well: DYes or .V11Nn r , copy clads., ,ird has been provided to:t:i wail owns,. ' •
I/Mkt is a repan;fill out known well emrsuvclion i Jor•tnation and explain the maim of the
repair under 1/21 remarks section or on the hack of this form. 23.Site diagram or additional well details: .
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
S.Number of wells constructed: _ _
For multiple injection or non-water supply wells ONLY with the same construction.you can
suhmii(wpm. SUBMITTAL.INS'I'UCTIONS
9.Total well deh below land surface: 744-' ,_,-,(rt.) 24a. Tgf,,(1,jj Weds: Submit this form within 30 days of completion of well
Fat multiple wells Iiist all depths if different(example.3 n 200'and 2®100') construction to the following:
10.Static water level below top of casing: 1,3a _ _(ft.) Division of Water Resources,Information Processing))nit,
1/water level is above casing use."a" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b. For lniectjon Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this firm within 30 days of completion of well
12.Well construction method: �,�. __ .___. cu>nsuuction to the tbllowiitg:
L( c.auger,t'otaty,cable,direct push,etc.)
__ ___ _ Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: _ T� �^ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(spar)_•.__ .JAir lift 24c.Fur Water Supply&Injection Wells:
Method of test: ..._...._
""""" Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:,H&.M Amount:.12 oz. well construction to the county health department of the county where
_....._....._..._._-_._...._T constructed.
Revised Augu st 201 J
Form OW-1 North Carolina Department of Environment and Natural Resources•-Division of Water Resources

Q,otecr + q35'17(L,(,Frankhn,NC28734
at gil •rn MaconCounty I � _R
Public Health (828)349—2490
�d ash-01/ /� �j [e-mail]
WELL CONSTRUCTION AUTHORIZATION
•
Owner Lee Adcock WEL 051024-1 SEP 052823-S
Location 10996 Bryson City Rd—Franklin, NC PID 6568887447 ACREAGE 4.61
Directions Bryson City Rd north toward Blackberry Ridge; next driveway on left.
Design Single-Family Well• Permit Type New Construction Expiration Valid for 60 Months
Highway 28/Bryson City Rd *
489'
00
Old House
Place
0.a
Po.i s`- Aro
ol
.. eat-o o ( �I Well Area
Tr-
% -r . En
86(
'`` 86 O•dt)
c/ � �.
Re;`, 6'6',.,49 , a -" 100'Min
4
Oidb . r57 '35' 66
f IP
431'
124'
85'
Diagram not to scale i
Permit Conditions
1) Well shall be constructed in compliance with all 15A NCAC 2C rules.
2) Maintain all minimum setbacks, were applicable.
3) When well and pump are completed, contact MCPH for inspection.
The issuance of this permit by MCPH in no way guarantees the issuance of other permits.The property owner is responsible for checking with appropriate governing
bodies in meeting their requirements.This permit is subject to revocation if the site plan,plat,site,or intended use changes.All rules in 15A NCAC 02C Well Construction
Standards are incorporated by reference into this document,including any subsequent amendments to those rules,and shall be adhered to.Please contact MCPH for
inspection when well head and pump installation are completed and you are ready to place well into service.
Any person abandoning a well must submit to MCPH Form GW-30 upon completion.
May 22, 2024 .7 G��--�
Issue Date Jere less, REHS 3157